In patients under 55 years with coronary artery disease, does percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) provide better long‑term outcomes?

CABG Provides Superior Long-Term Outcomes in Young Patients with Coronary Artery Disease

For patients under 55 years with coronary artery disease, CABG is the preferred revascularization strategy over PCI, particularly in those with diabetes mellitus, multivessel disease, or complex coronary anatomy, as it provides significantly better freedom from myocardial infarction and repeat revascularization despite similar mortality rates. 1, 2

Evidence from Young Patient Populations

The most recent and highest-quality evidence specifically examining young patients demonstrates clear advantages for CABG:

• In patients aged ≤50 years, CABG provides significantly superior 5-year freedom from major adverse cardiac and cerebrovascular events (85.0% vs 73.9%, p<0.0001) compared to PCI 1

• Freedom from repeat revascularization at 5 years is dramatically better with CABG (92.5% vs 77.6%, p<0.0001) 1

• Freedom from myocardial infarction at 5 years strongly favors CABG (96.6% vs 89.9%, p<0.0001) 1

• Long-term survival rates are similar between the two approaches (97.8% vs 94.9% at 5 years, p=0.082), indicating that the choice should be driven by morbidity and quality of life considerations 1

Critical Subgroup Considerations

Diabetes Mellitus (Strongest Indication for CABG)

Young diabetic patients derive the greatest benefit from CABG over PCI:

• In diabetic patients aged 18-45 years, CABG provides superior 10-year survival (97.5% vs 94.6%, p=0.0403) and freedom from recurrent MI (95.6% vs 92.5%, p=0.0260) 2

• Freedom from major adverse events in young diabetics is markedly better with CABG (75.9% vs 58.0% at 5 years, p<0.0001) 1

• The American College of Cardiology recommends CABG over PCI in patients with multivessel disease and diabetes mellitus, particularly when LIMA can be anastomosed to the LAD 3, 4

Multivessel Disease

• In young patients with multivessel disease, CABG provides substantially better freedom from major adverse events (85.1% vs 63.6% at 5 years, p<0.0001) 1

• CABG is recommended as first-line therapy for complex 3-vessel disease (SYNTAX score >22) to improve survival and reduce repeat revascularization 3, 4

Left Main Disease

• The American Heart Association recommends CABG as the overall preferred mode over PCI for left main disease given lower risk of spontaneous MI and repeat revascularization 3

• PCI is acceptable only when left main disease has low complexity (SYNTAX score ≤22) 3

The Exception: STEMI Presentation

PCI is superior to CABG when young patients present with ST-elevation myocardial infarction, providing significantly better 5-year survival (97.5% vs 88.8%, p=0.001) driven by lower 30-day mortality (1.5% vs 6.0%, p=0.017) 1

This represents the only clinical scenario where PCI should be preferred in young patients.

Practical Decision Algorithm for Young Patients

Choose CABG when:

• Diabetes mellitus is present with any multivessel disease 2, 3
• Multivessel disease exists (especially 3-vessel or left main) 1, 3
• SYNTAX score is ≥22 3, 4
• Proximal LAD involvement with multivessel disease 3
• Patient can tolerate surgery and has reasonable life expectancy 1

Choose PCI when:

• Presenting with acute STEMI requiring emergent revascularization 1
• Isolated single-vessel disease without diabetes 5
• Left main disease with low SYNTAX score (≤22) and low complexity 3
• High surgical risk contraindicates CABG 5

Require Heart Team Discussion when:

• Unprotected left main or complex CAD where choice is not straightforward 3, 4
• Patient preferences strongly favor less invasive approach despite anatomic indications for CABG 4

Technical Considerations for Young Patients

Total arterial revascularization should be prioritized in young patients when feasible, as approximately 52% of young CABG patients can receive complete arterial grafting 6

• Bilateral internal mammary arteries provide survival benefit in younger patients with multivessel disease 7

• LIMA to LAD has >90% patency at 10 years, far superior to venous grafts (25-50% at 10-15 years) 7

• Radial artery grafts show superior patency compared to saphenous vein grafts (89% vs 65-80% at 4-5 years) 7

Common Pitfalls to Avoid

Do not choose PCI simply because the patient is young and wants to avoid surgery – the data clearly show that young patients have excellent surgical outcomes (1% in-hospital mortality) and derive greater long-term benefit from CABG in most anatomic scenarios 6, 1

Do not underestimate the impact of repeat revascularization on quality of life – the 15% absolute difference in freedom from repeat revascularization at 5 years (92.5% CABG vs 77.6% PCI) represents a substantial burden of recurrent procedures and symptoms 1

Do not assume stroke risk favors PCI in young patients – freedom from stroke is equivalent between CABG and PCI at 5 years (98.0% vs 98.0%) in young patients, unlike older populations where this becomes a differentiating factor 1

Recognize that approximately 50% of young patients present urgently or emergently – only 48% are purely elective cases, requiring rapid decision-making about optimal revascularization strategy 6